Discharge Planning

Revisions to Requirements for Discharge Planning

Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies.

On November 3, 2015 the Centers for Medicare and Medicaid Services (CMS) published a Federal Register notice that would revise Conditions of Participation (CoP) related to discharge planning requirements that Hospitals, including Long-Term Care Hospitals and Inpatient Rehabilitation Facilities, Critical Access Hospitals, and Home Health Agencies must meet in order to participate in the Medicare and Medicaid programs. This proposed rule includes new elements to implement the discharge planning requirements of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT). Once finalized the rule will revise requirements in existing, as well as proposed, home health CoP and add new requirements. According to the notice, the rule focuses on preparing patients to be active partners in post-discharge care, to provide effective transitions of patients from home health agencies to post-home health agency care and reduce factors leading to preventable readmissions.

The Federal Register notice is available here. The home health agency requirements are detailed in section B. Home Health Agency Discharge Planning beginning on page 68137. If finalized as proposed, the regulations will require home health agencies to dedicate considerable additional resources to discharge planning activities. Home health agencies are urged to read the proposed rule notice and submit their suggestions and concerns about their potential effect on patient outcomes and agency operations to the Centers for Medicare and Medicaid Services (CMS). Comments can be submitted electronically up until 5PM on January 4, 2016 to http://www.regulations.gov by following the simple ‘‘Submit a comment’’ instructions.

In summary, CMS proposes to establish two new CoP standards:

A) ‘‘Discharge planning process,’’ to require that HHAs develop a discharge planning process and plan for each patient to ensure that the discharge goals, preferences, and needs of each patient are identified and:

  • Have regular reevaluation of patients to identify changes that require modification and update the plan as needed
  • Take reasonable steps to provide resources to individuals with limited English proficiency or other communication barriers
  • Have the physician responsible be involved in the ongoing process of establishing the discharge plan
  • Consider the availability of caregivers/ support persons and their capacity to perform required care
  • Assist patients and their caregivers in selecting a PAC provider by using and sharing data relevant and applicable to the patient’s goals of care and treatment preferences
  • Document the evaluation of the patient’s discharge needs and discharge plan
  • Establish more specific time frames for completing the evaluation and discharge plan taking into consideration the patient’s acuity level and time spent in home health care
  • Include the reevaluation in the clinical record
  • Discuss the results of the evaluation with the patient or patient’s representative
  • Incorporate all relevant patient information available to or generated by the HHA itself into the discharge plan.

B) ‘‘Discharge or transfer summary content,’’ to require HHAs to:

  • Send necessary medical information to the receiving facility or health care practitioner
  • Include, at the minimum, the following in the summary:
    • Demographic information, including but not limited to name, sex, date of birth, race, ethnicity, and preferred language;
    • Contact information for the physician responsible for the home health plan of care;
    • Advance directive, if applicable;
    • Course of illness/treatment;
    • Procedures;
    • Diagnoses;
    • Laboratory tests and the results of pertinent laboratory and other diagnostic testing;
    • Consultation results;
    • Functional status assessment;
    • Psychosocial assessment, including cognitive status;
    • Social supports;
    • Behavioral health issues;
    • Reconciliation of all discharge medications (both prescribed and overthe-counter);
    • All known allergies, including medication allergies;
    • Immunizations;
    • Smoking status;
    • Vital signs;
    • Unique device identifier(s) for a patient’s implantable device(s), if any;
    • Recommendations, instructions, or precautions for ongoing care, as appropriate;
    • Patient’s goals and treatment preferences;
    • The patient’s current plan of care, including goals, instructions, and the latest physician orders; and
    • Any other information necessary to ensure a safe and effective transition of care that supports the post-discharge goals for the patient
  • Consider having practitioners to consult with their state’s PDMP as part of the medication reconciliation process
  • Document all required elements, even proposed medical information elements that are not applicable by annotating the information with a ‘‘N/A’’ or other appropriate notation next to each data element that does not apply to the patient.
December 2, 2015

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